This form is for new applications for a permit to purchase poisons for use in a business for industrial purposes. This type of permit is most commonly issued for schedule 7 poisons. To request a change to an existing permit, please complete an Application to Change a Licence or Permit.
Applicants must complete a Personal Information Form: Identification, Fitness and Probity. If the permit is to be issued to a partnership, each partner must complete the personal information form. If the permit is to be issued to a corporation, each corporate officer (directors, company secretary, chief executive officer or general manager and chief financial officer) must complete the personal information form.
A responsible person must be nominated for each premises on the permit. Each nominated responsible person must complete a Personal Information Form: Identification, Fitness and Probity. The responsible person at a premises can be the same person as the applicant. Responsible persons must have a relevant qualification or experience handling the poisons on the permit.
Applications will generally be processed within 4 weeks of receipt by the Medicines and Poisons Regulation Branch, provided the required fee has been paid. To ensure a timely decision about your application please:
- Complete all required sections of the application,
- Attach all requested documentation to the application,
- Respond to requests from the Department for additional information as soon as possible and
- Make sure appropriate staff are available if the Department needs to conduct a premises inspection.
If the permit is issued it will expire 1 year after the date of issue. A renewal application will be mailed to the postal address approximately 2 months prior to expiry. If the permit is not issued, the applicant will be provided with details of the reasons in writing and the permit fee will be refunded. The application fee is non-refundable.
There are penalties under the Medicines and Poisons Act 2014 for providing false or misleading information.
If the permit is issued, it is the responsibility of the applicant (permit holder) to ensure compliance with the Medicines and Poisons Act 2014, the Medicines and Poisons Regulations 2016 and any conditions placed on the permit.
- Applicant
Name of Legal Entity (may be different to business or trading name):
Business or trading name:
Title: / Forename/s: / Surname:
Position in business:
Postal address: / Suburb: / Postcode:
Telephone: / Fax: / Email:
Permit to be issued to:
Abovenamed person on behalf of business / Partnership / Company or other incorporated body
Attach a completed and signed copy of the Personal Information Form: Identification, Fitness and Probity for the abovenamed person, each partner or each corporate officer as applicable.
Note: Applicant should have authority within the business to determine policies and procedures in relation to handling of poisons on the permit. The applicant can also be the responsible person at any of the premises on the permit, provided they have appropriate qualifications and/or experience in handling the poisons on the permit.
If the permit is to be issued to a company or other incorporated body,attach certified copy of the Certificate of Incorporation (such as from the Australian Securities and Investment Commission [ASIC]).
Australian Company Number of Australian Registered Body Number (if applicable):
If the business has a Business or Trading Name, attach a certified copy of Record of Registration of Business Name.
Australian Business Number (if applicable):
Registered business address of applicant: / Same as postal address shown above
Address: / Suburb: / Postcode:
- Purpose for which poisons will be used
Mining / Prospecting / Brick cleaning
Swimming pool chlorination / Water/effluent treatment / Pickling and passivation of stainless steel
Laboratory analysis - commercial / Jewellery manufacture - commercial
Other – please specify:
- Poisons required
Name, description (such as gel, liquid etc) and strength of poison / Approximate quantity kept on hand
- Qualification and experience
All applicants and nominated responsible persons must complete the Personal Information Form: Identification, Fitness and Probity.
For permits for chlorine gas ONLY, the responsible person for each premises must provide evidence of training in resuscitation and competency in the use of chlorine gas for the proposed purpose. In addition, please provide the names of all users of chlorine gas at each premises and for each person attach:
- Evidence of training in resuscitation and
- Evidence of competency in use of chlorine gas for the proposed use.
Name of chlorine gas user / Position in business / Evidence attached
Forename/s / Surname
- Premises details
If poisons will be stored at more than one premises, please complete section 5 and 6 for each premises to be included on the permit. You may also need to complete section 7,8 or 9 for each premises.
Street address: / Suburb: / Postcode:
Telephone: / Fax:
Date of possession of the premises (settlement date/lease commencement/handover of building):
Note: Permit will be issued with “Valid from” date on or after this date.
Name of Responsible Person at premises:
Note: The abovenamed person must complete a Personal Information Form: Identification, Fitness and Probity.
Location of storage address is: / Residential / Commercial / Industrial
Rural / Other – please specify:
Note: Local government will be asked to comment on applications where the premises address is residential and may be asked to comment on other applications. This may increase processing time.
Is a Dangerous Goods (DG) Site Licence required for bulk poisons at the premises?
Yes / No / Exempt from requiring a DG Site Licence.
If yes, please attach a copy of the DG Site Licence.
For applications to purchase poisons for use in Mining or Prospecting ONLY, please provide the following information:
Mining lease number:
If the mining lease is not held by the applicant (legal entity), please provide written approval from the lease holder for storage and use of the requested poisons on the lease.
- Security and storage
How are poisons stored and secured against unauthorised access?
Locked metal cabinet / Locked cupboard / Locked shed
Locked and covered caged area / Other – please specify:
Is the storage area for the poisons bunded? YesNo
- Laboratory analysis ONLY – additional information
Building security – please check all that apply:
Dedicated monitored alarm system / Motion detectors
Video surveillance system / Other – please specify:
Does the premises have a Water Corporation Industrial Water Permit for waste water discharge? / Yes / No
- Jewellery manufacture ONLY – additional information
Describe the ventilation of the area where poisons will be stored and used:
Where does the ventilation system exit?
Does the premises have systems to monitor the concentration of the poison gas (ppm) in the ventilation system? / Yes No
- Hydrofluoric acid ONLY – additional information
Will the hydrofluoric acid be used at other sites? YesNo
If yes, please describe how the hydrofluoric acid will be transported and secured?
What personal protective equipment (PPE) will be worn when using hydrofluoric acid?
Chemical safety goggles / Face shield / Long apron
Hats and hoods / Sleeve protectors / Safety boots
Gloves / Coveralls
Other – please specify:
I confirm that:
Hydrofluoric acid will be accessible only to people who are trained to use it.
Hydrofluoric acid will be used only by people who are trained to use it.
Calcium gluconate gel (in date) will be available on all sites where hydrofluoric acid is stored or used.
Running water will be available on all sites where hydrofluoric acid is stored or used.
- Declaration
I (provide full name):
of (provide full address):
hereby declare:
The information contained in this application form is true and correct
I am aware that penalties apply under the Medicines and Poisons Act 2014 for providing false or misleading information in this application.
Signature of applicant: / Date:
Please post completed form to: Health Support Services
PO BOX 8549, Perth Business Centre WA 6849MP00042
Payment enquiries: 1300 367 132 Page 1 of 6
PaymentFee: $300
Comprising non-refundable application fee $175 and 1 year permit fee $125
Permit fee only will be refunded if permit is not issued.
Cheque or money order – made payable to DEPARTMENT OF HEALTH
Credit Card – American Express and Diners not accepted
Card type: / MasterCard / Visa
Name on card: / Card number:
Expiry date: / Amount: / $300
Signature of cardholder: / Date:
Direct debit to bank
Bank: Commonwealth Bank / BSB: 066 040 / Account number : 13300018 / Amount: / $300
Receipt Number: / Payment date:
Please post completed form to: Health Support Services
PO BOX 8549, Perth Business Centre WA 6849MP00042
Payment enquiries: 1300 367 132 Page 1 of 6